Ethel M. Robertson, EdD, ENP-BC; Anett Wakefield Eranklin, MSN, ENP-BC; AnnMarie Elores, PhD, PT; Shari Wherry, MSN, ENP-C; and Juanita Buford, EdD African American Community Breast Health Education: A Pilot Project Abstract: This paper reports the results ofa project designed to examine the effectiveness ofa Train the Trainer breast health education and screening program for African American, elderly and underserved women residing in the greater Nashville area. The project aimed to identify a cadre of women from the community willing to serve as leaders advocated and peer breast health educators. Data collected from the community leaders and the women from the local community during the course of the project suggest that the Train the Trainer model was well suited to provide education, support and breast cancer resource referral to women residing within this rural Tennessee community. Key Words: Breast Health; African American Women; African American Community. One objective of Healthy People 2010 (2000) is to reduce the breast cancer death rate experienced by women the United States. Presently, African American women, when compared with women of other racial/ ethnic groups, have the highest mortality rate and the lowest survival rate after being diagnosed with breast cancer. Healthy People 2010 (2000) cited unequal access to providers, obstacles related to screening and diagnostic testing, cultural myths, and lack of knowledge as barriers to breast cancer screening and breast care for many minority women. African American women who live in rural areas who are poor and under-educated are likely to forgo recommended breast screenings. Consequently, when diagnosed with breast cancer they all too often present with distant disease. Concerned about the needs of underserved women within the greater Nashville area, the Nashville Affiliate of the Susan G. Komen Foundation conducted a community needs assessment. Following the review of the data collected during the needs assessment, the Affiliate identified a need The ABNF Journal " for projects and programs focusing on breast health education for low-income African American women living in several rural counties in Nashville. The U.S. Bureau of Census, Census 2000 indicated that the breast cancer incidence rate among non-white females in greater Nashville area was 63 percent in 1997. The area has a total population of 27,382 women. Thirty-nine (39) percent of the population graduated from high school. The greater Nashville area reports that 20.7% of their population is enrolled in a government insurance plan. There are over 900 poverty stricken families with children under 18 years of age, which is headed by single females IDENTIFYING AND TRAINING TRAINERS The Trainer the Trainer Minority Breast Health Education project was developed and implemented in the greater Nashville area in collaboration with the local health department and women in the community. The overall goal of the project was to educate elderly, underserved African American women from area about breast health, breast cancer screening and early detection and self-breast examination. The Train the Trainer program proposed to create a cadre of women in the community who would become leaders and peer-educators disseminating accurate breast health information, teach the technique of self-breast examination, and become liaisons for the African American women in the community and health care providers. Prior to the implementation of the program community leaders, directors of the County Health Department, directors of the local unit of the American Cancer Society, and coordinators of the Tennessee Mid-Cumberland Region Breast and Cervical Screening Program participated in a series of planning meetings. During these meetings trends in breast cancer incidence, mortality, and survival among African American and Hispanic women in the targeted rural county were reviewed and discussed; they reviewed breast health pamphlets, books, models, videos, notebooks, pens. January/February 2006
and bead necklaces for training purposes; they identified resources and services for medically underserved women available for breast cancer detection and control in the local community; and, they developed a breast cancer trainer curriculum and a presentation outline for use in community education and outreach.. After developing the training curriculum program trainers were sought. Prospective trainers, many of which were referred to the program by the community leaders involved in the program development and planning, were invited to participate in a Train the Trainer workshop. To be eligible to serve as program trainer prospective participants were required to be residents of the target county; willing to participate in a two-day Train the Trainer workshop; and, willing to organize and teach two community breast health education sessions. During the training sessions, didactic information about breast health, breast cancer screening and breast cancer control were presented; hands-on- training in self-breast examination were provided; and, directions and ideas on how to conduct community workshops was provided. While several women expressed an interest in becoming trainers for the project, only five women completed the training for this project. After completing the training the women decided to collaborate in the conduct of their community education programs. After identifying training sites, the trainees created fliers, announcements and invitations for the community breast health education and breast cancer screening program for presentation and distribution at area churches, worksites, and community centers. Five community education sessions were offered by the program trainees. Four sessions " were held at local churches while the fifth session was conducted in a classroom at a local private school. A program evaluation tool was used to assess the program impact. The tool, designed as a retrospective self-evaluation was used to assess knowledge relative to breast cancer detection and control among African American and Hispanic women before and after the participation in the community program. Items that assessed prior participation breast health education programs were also included in the tool. PROGRAM PARTICIPANTS Sixty-three women from the greater Nashville community participated in the breast health educational programs provided by the trainers. However, demographic and program data were collected from only of the participants (Table 1). Twenty-one participants chose not to complete the program evaluations citing the perceived personal nature of the questions. Sixteen of the women involved in the community programs were Hispanic could not read English well enough to complete the survey. Three of the women wanted to listen and observe, without interaction or participation. The participants completing the program evaluation ranged in age from 21 to 74 years with a mean age of 40 years (SD = 9.5). Eighty three percent of the participants self-identified as African American (n = 19). Seventeen percent of the participants self-identified as Hispanic (n = 4). Forty three percent of the participants had a first-degree relative that had been diagnosed with breast cancer (n = 10). Thirteen percent of the participants were breast cancer survivors (n = 3). Most of the participants (48%) completed high school. Sixty one percent of the participants reported a family income greater than $30,000 per year (n= 14). Twenty one percent of the participants reported family incomes of less that $15,000 per year (n =6). Seventy percent of the participants reported having private health insurance through their place of employment which Table 1. Characteristics of the Project Sample* Age <50 yrs > 50 years Education >High School College or Greater Ethnicity African American Hispanic Income <$30k >$30K Type of Insurance Government or None Private Pay Ever had a mammogram Never Within one year More than 2 years ago Occupational Skilled Professional Retired Frequency 12 11 14 9 19 4 8 16 6 17 7 13 2 13 8 2 Percent 52.2 47.8 60.9 39.2 82.6 17.4 34.8 65.2 26.2 73.9 30.4 56.5 8.7 56.5 34.8 7.6 paid for yearly mammograms, clinical breast examinations and yeariy office visits (n =16). Government insurance which included Medicare or TennCare was utilized by of the participants (n =6). One participant reported that she did not have insurance coverage. PROGRAM OUTCOMES When asked about previous participation in a breast health education programs, none of the participants reported having ever participated in a formal or informal breast health education program. When asked the reasons for not participating several of the women commented, "I don't have any family members who have had breast cancer", "I do not want to be asked to expose my breast", "I might find out something bad." One woman noted that she did not participate because she "Had to attend to something more important at the same time". Another stated that, "It was too hard to find a baby sitter at the time of the meeting ". The women involved in the community education and outreach reported being pleased to have been included in the breast health training and outreach sessions and pleased to have been taught by women that knew and that they could understand. Data suggested that prior to the program while the women recognized the importance of breast cancer screening they had limited knowledge about breast cancer, changes in their breast that warranted medical attention, and breast cancer resources available to them in their local community (Table 2). However, data suggested that following participation in the programs facilitated by the community trainers their
Table 2. Results of Community Edueation and Outreach Program Evaluation Before the Program After the Program N Low to Moderate Fairly High to Extensive Unchanged to Increased a Little increased Somewhat to Great Deal Knowledge of breast cancer trends among African Americans 81% 11% 78% Knowledge of breast cancer trends among breast cancer among Hispanic women 87% 13% 57% Knowledge of factors that could increase a woman's chance of developing breast cancer 73% 22% 78% Knowledge of the importance of breast cancer screening 56% Understanding of the three procedures recommended for screening for breast cancer 61% 3 35% Understanding of the importance of self-breast examination to breast cancer control 48% 52% Understanding of the importance of a nurse or physician examining your breast annually for breast cancer 56% 92% Understanding of the importance of mammography breast cancer control 83% Awareness of changes in the breast that require immediate medical attention 3 8% Ability to recognize changes in the breast that would require immediate medical attention 95% Knowledge of what to do in performing a breast self-examination 61% 3 96% Ability to perform a breast self-examination 35% Knowledge of breast cancer screening facilities within the community 70% 30% 95% Knowledge of ways that families and groups in the community can reduce the burden of breast cancer African American women 86% 13% Knowledge of ways that families and groups in the community can reduce the burden of breast cancer experienced by Hispanic women 82% 83%
knowledge about breast cancer, changes in their breast that warranted medical attention, the importance of breast cancer screening to breast cancer control, and breast cancer resources available to them in their local community had significantly increased. SUMMARY The findings from this project have implications for nurses, educators, researchers. The projects directors learned that identifying African American women who are considered to be leaders in their community must be an open and evaluative process. Once identified and trained the women used their influence in their church, places of employment and community resources to present the community educational sessions. The women embraced the cause of breast health and demonstrated that they were truly community champions for breast health. As a result, at the completion of the project the health education efforts begun by this group of community leaders will continue. The efforts will continue because a cadre of committed African American and Hispanic women became equipped with information and knowledge and because the women are willing to assume leadership roles in their own communities and are willing to counsel, share, encourage, and champion breast health. REFERENCES Bigby, J., Ko, L., Johnson, N., & David, MM. (2003, July- August). A community approach to addressing excess breast and cervical cancer mortality among women of African descent in Boston. Public Health Representative, 18(4), 338-347. Champion, V., Maraj, M., Hui, S., Perkins, A.J., Tierney, W., Menon, tj., & Skinner, CS. (2003). Comparison of tailored interventions to increase mammography screening in nonadherent older women. Preview Medicine. 36(2), 105-158. Gulitz,F., Bustillo-Hernandez, M., & Kent, E.B. (1998, November-December). Missed cancer screening opportunities among older women: A provider survey. Cancer Practice. 6(6). 325-332. U.S. Department of Health and Human Services. Healthy People 2010. 2'"' ed. With Understanding and Improving Health and Objectives for Improving Health. 2 vol. Washington, DC: U.S. Government Printing Office, November 2000. Leslie, N.S., Deiriggi, P., Gross, S., DuRant, E., Smith, C, & Veshnesky, J.G. (2003, July-August). Knowledge, attitudes and practices surrounding breast cancer screening in educated Appalachian women. Oncology Nurse Forum. 30(4), 659-667. Rudd, R., Kursch, I., & Yamamoto, K., (2004) Literacy and Health in America Policy Information Report, www.ets.org/ research/pic Schairer, C., Mink, PJ., Carroll, L., & Devesa, S. (2004, September). Probabilities of death from breast cancer and other causes among female breast cancer patients. Journal of National Cancer Institute. 1(96), 1311-1321. Susan G. Komen Breast Cancer Foundation. Breast cancer screening recommendations. Retrieved March 3, 2005, online from http://www.komen.org. Underwood, S., Canales, M., Reifenstein, K., & Swinney, J. (2005). Expanding and Strengthening Research Focused on Breast Cancer in African American Women: Building upon what is known. Journal of Chi Eta Phi. (Publication pending.) West, D.S., Greene, P., Pulley, L., Kratt, O., Gore, S., Weiss, H., & Siegfried, N. (2004). Stepped-care, community clinic interventions to promote mammography use among low-income rural African American women. Health Education Behavior. 4, 29S-44S. Ethel M. Robertson, EdD, FNP-BC, is an assistant professor at Meharry Medical College in Nashville, Tennessee. The other four authors are also from Meharry Medical College. They are: Anett Wakefield Franklin, MSN, FNP-BC, is an instructor, AnnMarie Flores, PhD, PT, is an assistant professor, Shari Wherry, MSN, FNP-C, is an instructor; and Juanita Buford, EdD, is assistant professor and senior research analyst. Gloucester County College Nursing Faculty Fall 2006 Gloucester County College invites applications for two ten-month, tenure-track positions in Nursing - Psychiatric Mental Health and Med/Surg. Applicants with expertise in Women's Health and Peds welcome. Master's degree in nursing required; PhD preferred. RN license required; minimum of two years' clinical experience in a healthcare setting and demonstrated leadership and teaching experience required. Please visit our website www.gccnj.edu to apply and to learn more about these positions. Fully paid benefits package. Women and minorities encouraged to apply. EOE/AA Open until filled